Email address *

Password * Must contain at least one number and one uppercase and lowercase letter, and at least 8 or more characters

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First Name *

Last Name *

Address 1 *

Telephone Number (Mobile) *

City *

County *

Postcode *

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Prescriber Type * -- Prescriber Non-Prescriber

Medical Registration Body * -- NMC GMC GDC GPHC OTHER

GMC/GDC/GPHC/NMC *

Upload Photo ID - Passport/Driving Licence *

Upload Utility Bill from Last 3 Months
We do NOT accept
- Provisional driving licence, Mobile phone bills, Credit card statements.
We do accept
- Gas, electric, satellite television, landline phone bill issued within the last three months, Local authority council tax bill for the current council tax year, Bank, Building Society or Credit Union statement or passbook dated within the last three months. *

Dermal Filler Certificate *

Aesthetic Insurance Document
(please, upload your full insurance policy schedule for aesthetics, including expiry dates and treatment lists) *

Signature uploaded successfully, to view or edit, please click on the above button.

Create a Unique 4 Digit PIN * This PIN is unique to you & it is your responsibility to keep it safe. It will be used to sign prescriptions. You must not share this with anyone else as anyone else signing your prescriptions is FRAUD and could result in prosecution and removal from the professional register.

Highlight your training from the following list (please tick all that apply) * Dermal Fillers
Toxin
Fat Dissolving
B-12 Injections
Semi Permanent Make Up
Plasma Pen
Prescriber Only
Chemical Peels

How did you hear about us? * -- Instagram Facebook Radio Ad Google search Word of mouth Referred by a friend Other

Other *

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